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FIGURE 552.3 A: Necrotic pressure sore involving the Achilles tendon in a pareparetic woman who also had
significant atherosclerotic peripheral occlusive disease. B: A more caudal 8 × 3.5-cm horizontal bipedicled
fasciocutaneous flap was raised and transferred superiorly, capturing inflow from both sides of the Achilles
tendon. C: This allowed successful healing and avoidance of limb amputation in a difficult situation.
OPERATIVE TECHNIQUE
Once the flap boundaries have been marked, the margin furthest from the flap base should be raised first to
identify the plane under the deep fascia. Rapid and bloodless dissection toward the flap pedicle should follow
until inset without tension is possible. A small backcut in the deep fascia, avoiding any vascular structures, can
facilitate this. Paratenon, if exposed, is carefully preserved, or tendons are buried under adjacent soft tissue to
enhance the take of a skin graft, invariably required to close the donor site. Postoperative immobilization and
bedrest are obviously important to ensure healing and must be enforced.
CLINICAL RESULTS
Intrinsic local flaps of the dorsum of the foot include the extensor digitorum brevis muscle flap (7) and the
dorsalis pedis and lateral calcaneal cutaneous flaps (8, 9). Elevation of the first two can compromise
circulation of the foot by sacrificing a named source vessel; the latter flap often has no single distinct artery,
but rather multiple terminal branches, often also becoming a Pontén-type of flap that depends on multiple
fascial perforators (2).
Extrinsic skin territories in the leg can be used as distally-based flaps to resurface the foot or ankle, without
sacrifice of a source vessel. However, they may be multistaged procedures and can cause significant
cosmetic donor-site morbidity (10). Acceptable donor-site morbidity must also be considered before using
any of the local Pontén-type intrinsic flaps as well (Fig. 552.2). Therefore, a free flap might be a better
selection and remains an appropriate choice if insufficient local tissue is unavailable (1).
Nevertheless, for small defects, the morbidity and risk of failure involved in microsurgical transfer can be
avoided entirely by using the simple local flap described. For the polytrauma patient with compromised
vascularity, these Pontén-type fasciocutaneous flaps may be the only alternative to limb amputation.
SUMMARY
A “random,” local, fasciocutaneous flap from the dorsum of the foot or ankle can often solve the problem of
covering small defects, without resorting to a free flap.
References
1. Hallock GG, Rice DC, Keblish PA, Arangio GA. Restoration of the foot using the radial forearm flap. Ann
Plast Surg 1988;20:12.
2. Hallock GG. Fasciocutaneous flap skin coverage for the dorsal foot and ankle. Foot Ankle 1991;11:274.
3. Hidalgo DA, Shaw WW. Anatomic basis of plantar flap design. Plast Reconstr Surg 1986;78:6227.
4. Pontén B. The fasciocutaneous flap: Its use in soft tissue defects of the lower leg. Br J Plast Surg
1981;34:215.
5. Ishiskawa K, Isshiki N, Hoshino K, Mori C. Distally based lateral calcaneal flaps. Ann Plast Surg
1990;24:10.
6. Hallock GG. Bipedicled fasciocutaneous flaps in the lower extremity. Ann Plast Surg 1992;29:397.
7. Hing DN, Buncke HJ, Alpert BS. Applications of the extensor digitorum brevis muscle for soft tissue
coverage. Ann Plast Surg 1987; 19:530.
8. Smith AA, Arons JA, Reyes R, Hegstad SJ. Distal foot coverage with a reverse dorsalis pedis flap. Ann
Plast Surg 1995;34:191.
9. Grabb WC, Argenta LC. The lateral calcaneal artery skin flap (the lateral calcaneal artery, lesser
saphaenous vein, and sural nerve skin flap). Plast Reconstr Surg 1981;68:723.
10. Lagvankar SP. Distally-based random fasciocutaneous flaps for multi-staged reconstruction of defects in
the lower third of the leg, ankle, and heel. Br J Plast Surg 1990;43:541.
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Chapter 553
Anterolateral Thigh Flap
T. BÉGUÉ
A. C. MASQUELET
EDITORIAL COMMENT
This is another flap that can be useful for reconstruction in the lower extremity when there are few other
alternatives.
The anterolateral thigh is a useful and reliable septocutaneous flap for free-flap transfer. Its dimensions are
easily applicable for large defects of the lower limb that involve the distal third of the leg, dorsum of the foot, and
plantar sole (1, 2, 3, 4, 5, 6, 7).
INDICATIONS
The anterolateral thigh flap is a wide, fasciocutaneous flap elevated on a perforating artery issuing from the
lateral circumflex
artery. Vascularized by a direct vascular bundle, with two terminal branches following the main axis of the
flap, it is easy to elevate for free-flap transfer. As its pedicle is long enough to allow its use in areas where
recipient-site vessels are distant from the defect to be covered, the main indications are cutaneous defects
of the distal leg, including the distal fourth of the leg, the ankle, the heel, and the forefoot. Its most
successful utilization is for large defects exposing tendons, nerves, and even bone and joints, on the
dorsum of the foot. Large heel defects, including those of the plantar sole, may also be covered by this flap.
There are no indications for its use in the upper extremity, as the subcutaneous fat tissue makes the flap
too thick for this recipient site.
The main advantages are reliability of vascularization of the skin paddle in the mid-flap, and the large
dimensions of tissue that can be elevated. Its main inconvenience is that the donor site cannot be closed
directly in the majority of flaps designed. The cosmetic aspect of a skin graft on the anterolateral thigh may
be unacceptable to some patients.
ANATOMY
The arterial and venous blood supply of the flap comes from branches issuing from the femoral artery and
returning to the femoral vein. The artery at the origin is the lateral thigh circumflex artery. One of the collateral
branches of this vessel is the descending branch of the circumflex artery, which leaves the lateral-thigh
circumflex artery on its lateral side, gliding beneath the rectus femoris and in front of the vastus lateralis muscles.
At this level, the muscular branches to the different segments of the quadriceps leave the main axis of the artery,
which courses downward and laterally. The cutaneous branch follows this intermuscular space, lying on the
vastus lateralis muscle. The vessel crosses the anterolateral thigh aponeurosis and divides into two axial
cutaneous branches (proximal and distal), which have a longitudinal axis and give off many cutaneous branches
to the skin paddle.
The cutaneous branch of the descending circumflex artery has a regular caliber of 1 mm at its origin, and the
length of the pedicle averages 5 cm.
The venous pattern of the flap has the same axis, parallel to the arterial system all the way from the skin to the
intermuscular space between the vastus lateralis and rectus femoris muscles. At this level, the anatomy is more
variable. In most cases, the vein remains with the artery, going up to the lateral circumflex vein and then to the
femoral vein. In the remaining cases, the vein goes more medially, with a transverse axis to the superficial lateral
femoral vein, ending in the greater saphenous vein proximal to the femoral vessel.
Nerve distribution comes from cutaneous nerves issuing from the anterolateral aspect of the thigh and entering
the flap near its anterosuperior border. No anastomosis to produce sensibility is reliable, as the nerves are too
small and are randomly distributed.
FLAP DESIGN AND DIMENSIONS
Used as a free-flap transfer, flap length and width are designed to meet the required dimensions of the recipient-
site defect. The flap is elevated on the anterolateral aspect of the thigh, with an axis joining the anterosuperior
iliac spine to the superolateral angle of the patella. The center of the flap corresponding to the perforating
vascular bundle through the aponeurosis is at the junction of the upper and middle thirds (Fig. 553.1). From that
point, flap design must maintain a 2:1 length:width ratio. The maximal length available is 30 cm, and the maximal
width is 15 cm. For direct closure of the donor site, after subcutaneous release of the flap margins, the largest
available dimensions are 8 cm in length and 4 cm in width.
FIGURE 553.1 Skin landmarks (anterosuperior iliac crest, lateral border of patella) and emerging vascular
bundle at junction of proximal third and distal two-thirds.
OPERATIVE TECHNIQUE
Measurements at the recipient site are recorded, so that the length and width of the anterolateral thigh flap can
be properly designed. The center of the skin paddle on the lateral aspect of the thigh is determined by the
emerging cutaneous branches of the descending branch of the lateral circumflex artery. If in doubt, detection of
the vessel by Doppler flowmetry may be useful. The flap is centered and designed according to the emerging
point of the artery (Fig. 553.1). Depending on the case, the flap can be drawn more proximal or distal from this
point. In any event, the emerging point must be included in the flap design.
To perform an easy dissection, the patient is placed in the supine position with a sandbag under the buttock.
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Moderate internal rotation of the limb allows greater facility of dissecting. The distal part of the flap is elevated
first, with dissection going deep to the aponeurosis. (We used to fix the aponeurosis to the skin to avoid
dissection between these tissues.) The intermuscular space between the rectus femoris (medially and anteriorly)
and the vastus lateralis muscles (laterally and posteriorly) is identified. The posterior and anterior borders of the
flap are then raised, leaving in place the intermuscular space and perforating vessels coming through it.
At that point, the vascular pedicle is identified by retracting the rectus femoris muscle medially. The main artery
and vein are isolated and elevated from the vastus lateralis behind them. Then, the intermuscular space is freed,
with ligature
of the accessory perforating vessels coming through it to the distal cutaneous portion of the flap. Sometimes, the
vascular bundle does not lie on the vastus lateralis, but passes through a thin layer of the muscle. Careful
dissection of the vastus lateralis allows the elevation of the vascular pedicle. The skin paddle and emerging
cutaneous vascular pedicle through the intermuscular space are elevated (Fig. 553.2).
FIGURE 553.2 Complete dissection of the flap and its pedicle emerging from intermuscular space with fatty
tissue.
If a longer vascular pedicle is required, dissection can be done medially beneath the rectus femoris muscle, by
retracting it and ligating the muscular vessels (Fig. 553.3). The pedicle length will be 10 cm, and the diameter at
its origin averages 1.8 mm. Dissection is done simultaneously for the artery and vein. If extended medially to the
rectus femoris muscle, venous anatomic variations may be encountered, as previously mentioned.
CLINICAL RESULTS
Most of the cases we have treated with the anterolateral flap have involved free-flap transfers for coverage
of defects of the foot and ankle (2). In some cases, the flap may be used as a rotation flap for coverage of
defects around the trochanteric area, like pressure sores. In these cases, the same operative procedure is
used, with rotation along the vascular pedicle in a clockwise direction for the left limb and in a
counterclockwise direction for the right limb, which allows sufficient coverage of the trochanteric area.
FIGURE 553.3 Medial dissection and muscular vessels to be ligated for a longer vascular pedicle; only the
rectus femoris and sartorius should be retracted. (From Bégué et al, ref. 2, with permission.)
Used in whatever clinical situation, we remind the surgeon of the thickness of the flap; the anterolateral
aspect of the thigh has a large amount of subcutaneous fat. Therefore, the flap is not suitable for areas
where a thin skin flap is required. However, the flap is thick enough for all pressure-sore areas to be
covered.
SUMMARY
The anterolateral thigh flap is a useful septocutaneous flap for free transfer and is especially useful for large
defects of the lower limb.
References
1. Baird RD, Cope JS. On the terminations of the circumflex veins of the thigh and their relation to the origins
of the circumflex arteries. Anat Rec 1933; 57:325.
2. Bégué T, Masquelet AC, Nordin JY. Anatomical basis of the anterolateral thigh flap. Surg Radiol Anat
1990;12:311.
3. Koshima I, Kukuda H, Utonomiya R, Soeda S. The anterolateral thigh flap: variations in its vascular
pedicle. Br J Plast Surg 1989;42:260.
4. Masquelet AC, Romaña MC. Vascularisation tejgumentaire des membres et applications chirurgicales. Rev
Chir Orthop 1988;74:669.
5. Salmon M. Les artères de la peau. Masson: Paris, 1936.
6. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous
artery. Br J Plast Surg 1984;37:149.
7. Xu DC, Zong SZ, Kong JM, et al. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg
1988;82:305.
Chapter 554
Alternative Vascular Pedicle of The Anterolateral Thigh Flap: The
Oblique Branch of The Lateral Circumflex Femoral Artery
NIDAL FARHAN ALDEEK
FU-CHAN WEI
EDITORIAL COMMENT
The oblique branch of the ALT flap adds further safety and variety in harvesting this flap.
INDICATIONS
The anterolateral thigh (ALT) flap, first described by Song et al. (1) based on septocutaneous skin vessels,
was popularized by Wei et al. (2) as a perforator flap supplied largely by myocutaneous perforators. In
practice, the flap has evolved into a workhorse soft-tissue flap for a variety of reconstructive needs (2).
The ALT flap is notorious for vascular variations. Kimata et al. (3) described eight branching patterns of the
ALT flap perforators. The authors classified types 4, 5, 6, 7, and 8 as a “nutrient perforating artery” arising
directly from the lateral circumflex femoral artery (LCFA), profunda femoris, or femoral artery itself. Similarly,
Shieh et al. (4) noted that 32% of perforators arose directly from the transverse branch.
Unlike previous studies, we prefer to call this innominate vessel the oblique branch of the LCFA because
this vessel (when present) is sizable and can reliably be used as the flap pedicle. We believe that labeling
this as a perforator would imply that it is much smaller and would require perforator- to-perforator
anastomosis “supramicrosurgery,” which, based on extensive experience with the ALT anatomy, is
inaccurate and misleading (5).
The clinical significance of the oblique branch is as follows. (a) Alternative pedicle of the ALT flap: But for
the ALT myocutaneous flap, the oblique branch can only supply the proximal segment of the muscle, and
therefore, if larger and/or distal segments of the muscle are needed, the descending branch should be
utilized instead. (b) The oblique branch adds to the versatility of the ALT flap, as it allows combined ALT
flap designs based on both the descending and the oblique branches. In such combined flaps, when the
oblique branch is type 1 or 2 (see Anatomy section below), it is dissected until the oblique and descending
branches converge to one pedicle. In this case, one set of microanastomosis will be needed, but in types 3
to 5, both branches do not converge to one pedicle. Therefore, two sets of anastomosis may be needed
(Fig. 554.1), and (c) when the oblique branch coexists along with the descending branch, two sequential
ALT flaps are possible, which is a useful refinement if the first flap fails or a tumor recurrence develops.
ANATOMY
The oblique branch is usually visible lateral to the descending branch in the upper part of the thigh. It runs for a
variable distance in the intermuscular septum before piercing the substance of the vastus lateralis muscle,
usually in the proximal third of the muscle. It may take origin from (a) the descending branch, (b) the transverse
branch, (c) the lateral circumflex femoral artery, (d) the profunda femoris, or (e) even directly from the femoral
artery (5). Based on its origin, we classify the oblique branch into types 1 to 5 as shown in Figure 554.2. Skin
vessels arising from the oblique branch are located in the proximal third and/or middle third of the thigh. They
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tend to be septal or septomyo skin vessels with a short, superficial intramuscular course or myocutaneous
perforators with a long intramuscular course.
FLAP DESIGN AND DIMENSIONS
A line is drawn between the anterior superior iliac spine (ASIS) and the midpoint of the lateral border of the
patella, representing the intermuscular septum between the rectus femoris muscle and the vastus lateralis
muscle. The midpoint of this line is marked, and handheld Doppler examination is performed. A standard 22- × 8-
to 9-cm ALT flap is designed, centered along the previous ASIS-patella line, capturing audible skin vessels (Fig.
554.3). A pinch test is performed to ensure primary closure of the donor site.
FIGURE 554.1 Combined oblique and descending ALT myocutaneous flap.
FIGURE 554.2 A schematic diagram illustrating the possible origins of the oblique branch. Dashed lines: The
oblique branch at its possible origins. Numbers represent respective types of the oblique branch based on origin.
LCFA, lateral circumflex femoral artery.
FIGURE 554.3 Standard markings and design for the ALT flap.The black lines are to define the boundaries of
possible ALT myocutaneous flap based on the oblique branch.
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FIGURE 554.4 ALT flap based on the oblique branch.
OPERATIVE TECHNIQUE
The anteromedial incision is made first. Then, dissection proceeds laterally in the suprafascial or subfascial
plane. The intermuscular septum is identified but not opened, and septal skin vessels are noted, if they exist.
The vicinity of the vastus lateralis muscle is explored, and the myocutaneous perforators are noted. Next, the
intermuscular septum is opened and the descending branch is located. Sometimes, a distinct vascular pedicle
located lateral to the descending branch exists in the proximal thigh. This branch is designated as the oblique
branch of the LCFA. Next, the desirable skin vessels are selected and then unroofed in a retrograde direction by
minimal cutting of roofing muscle fibers. Vessel unroofing is complete when the entire course of the skin vessel
and its source artery is clear. The oblique branch, if it exists, is selected as the flap's pedicle, based on the
reconstructive needs (Figs. 554.4 and 554.5). The skin vessel(s) and their pedicles are dissected. In the oblique
branch-based ALT myocutaneous flap, skin vessels are only unroofed, and a small, viable segment of the
proximal vastus lateralis is designed along the perforator and harvested with it as one unit. The posterior border
of the skin paddle is cut after the defect boundaries become clear. The flap is then transferred to the defect, and
the donor site is closed primarily.
FIGURE 554.5 Multiple perforator ALT flap based on the oblique branch.
CLINICAL RESULTS
In a series of 88 ALT flaps (5), a distinct oblique branch was noted in 31/88 patients (35%). The mean
diameter of the artery was 1.5 mm (range, 0.5 to 3.0 mm) at its origin and the mean pedicle length was 12
cm (range, 8 to 17 cm). It is accompanied by paired venae comitantes of comparable diameters and usually
accompanied by a branch of the motor nerve to the vastus lateralis. The oblique branch was classified
based on its origin into five types; types 1 and 2 accounted for 87% of all types.
Of all ALT flaps harvested, 12 of 88 (14%) were harvested based on the oblique branch. Of them, 10 were
fasciocutaneous and the remainder were myocutaneous flaps. Sixty percent of skin vessels were found in
the proximal third (a skin vessels).
All flap transfers based on the oblique branch of the LCFA were successful.
SUMMARY
The oblique branch has a relatively high occurrence in the lateral thigh, it has adequate length and diameter
for successful free tissue transplantation, and it robustly nourishes the lateral thigh skin and the proximal
part of the vastus lateralis muscle, allowing versatile ALT flap design.
References
1. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous
artery. Br J Plast Surg 1984;37:149-159.
2. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue flap? An experience with 672
anterolateral thigh flaps. Plast Reconstr Surg 2002;109:2219-2226.
3. Kimata Y, Uchiyama K, Ebihara S, et al. Anatomic variations and technical problems of the anterolateral
thigh flap: a report of 74 cases. Plast Reconstr Surg 1998;102:1517-1523.
4. Shieh SJ, Chiu HY, Yu JC, et al. Free anterolateral thigh flap for reconstruction of head and neck defects
following cancer ablation. Plast Reconstr Surg 2000;105:2349-2357.
5. Wong CH, Wei FC, Fu B, et al. Alternative vascular pedicle of the anterolateral thigh flap: the oblique
branch of the lateral circumflex femoral artery. Plast Reconstr Surg 2009;123(2):571-577.
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Chapter 555
Posterior Calf Fasciocutaneous Flap With Distal Pedicle to
Reconstruct Ankle Defects
D. LE NEN
W. HU
C. LEFEVRE
EDITORIAL COMMENT
Our anatomic knowledge of the intermuscular perforators or so-called septocutaneous vessels allows us to
design a fasciocutaneous flap, whether proximally or distally based or even as an island flap, as one
septocutaneous vessel is maintained alongside the flap. The limiting factor is that the lowest
septocutaneous vessel usually arises about 6 cm above the malleolus.
A distally-based, posterior-calf fasciocutaneous flap can be used to cover large ankle defects with exposed
bones and joints.
INDICATIONS
Coverage of a major ankle defect with exposed bones or joints after acute injury remains a difficult problem.
Local flaps are not usually indicated, and the choices for coverage are a cross-leg flap or a free flap. Since
its introduction in 1983 (1), a distally-based fasciocutaneous flap from the sural region has been used with a
high rate of success for large ankle defects (2). Reports of the flap based posteriorly or laterally for
reconstruction of the distal third of the leg, ankle, and heel have shown variable success (3, 4, 5). Among its
advantages, the flap is relatively wide and reliable. It can be harvested without functional loss and is easily
dissected. In addition, it is rapidly elevated, does not require microvascular anastomosis, and provides a
good cosmetic result.
FIGURE 555.1 The ankle defect involved skin, all lateral tendons, ligaments, capsule, distal fibula, and
lateral third of the talus, tibia, and calcaneus. (From Le Nen et al., ref. 2, with permission.)
Among the disadvantages are the necessity for a two-stage procedure. Also, the saphenous nerve must be
sacrificed. A twist at the base required by flap design may compromise the vascular supply, and the
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extensive fasciocutaneous pedicle decreases the arc of rotation. Coverage of more distal defects cannot be
achieved, because this flap does not reach the forefoot.
FIGURES 555.2 and 555.3 A posterior-calf fasciocutaneous flap with distal pedicle was elevated and
turned back over the ankle. The distal part of the defect was easily covered by the flap. (From Le Nen et al.,
ref. 2, with permission.)
ANATOMY
The flap receives its arterial blood supply distally in various ways: from a branch of the peroneal artery (6), the
saphenous venous plexus (6), and the fasciocutaneous network (3).
FLAP DESIGN AND DIMENSIONS
After division of the saphenous nerve and vein (see Fig. 555.2), the flap should be elevated from proximal to
distal, including the fascia. The distal limits of flap viability, indicating the maximal survivable length, lie about 10
cm above the medial malleolus and 12 cm above the lateral malleolus.
OPERATIVE TECHNIQUE
A posterior-calf fasciocutaneous flap was designed, outlined, and elevated to cover an ankle defect with skin
loss and loss of all lateral tendons, ligaments, capsule, distal fibula, and lateral third of the talus, tibia, and
calcaneus (Figs. 555.1 and 555.2). In this patient, the branch of the peroneal artery was not available because of
the wide lateral defect, and the saphenous nerve was already damaged. After elevation, the flap was turned
back over the ankle and easily reached the distal edge of the defect (Fig. 555.3). The donor site was not grafted
at this time.
FIGURE 555.4 Ten months postoperatively, the cosmetic result was excellent. (From Le Nen et al., ref. 2, with
permission.)
CLINICAL RESULTS
Wound healing was complicated by a small area of necrosis at the distal margin, which was excised after 10
days. The defect healed spontaneously by scar epithelialization, without advancement of the flap or skin
graft. The donor site was covered 21 days postoperatively by a split-thickness skin graft, which healed with
no problems. At this time, the pedicle was divided.
After 3 months, an iliac crest bone graft was screwed laterally onto the tibia to prevent ankle instability. On
2-year follow-up, the patient remained free of osteomyelitis, with an excellent cosmetic result; however, the
range of motion was poor (Fig. 555.4).
SUMMARY
A modified medial plantar flap, based on the lateral plantar artery and vein with reversed flow, can cover
any area of the foot.
References
1. Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural region: a preliminary report.
Scand J Plast Surg 1983; 17:191.
2. Le Nen D, Riot O, le Noach JF, et al. Use of a posterior calf fasciocutaneous flap with distal pedicle to
reconstruct a huge ankle defect. Arch Orthop Trauma Surg 1992;111:291.
3. Greco JM, Simons G, Darsonval V, et al. Le lambeau fasciocutane jambier exteme a pedicle distal. Ann
Chir Plast Esthet 1986;31:109.
4. Le Huec JC, Chauveaux D, Bovet JL, et al. Intérét du lambeau fasciocutané sural à base distal pour la
couverture des pertes de substance du tiers inférieur de jambe. Rev Chir Orthop 1988;74(Suppl. II):324.
5. Tolhurst DE. Surgical indications for fasciocutaneous flaps. Ann Plast Surg 1984;13:495.
6. Casey R, Darsonval V. Les lambeaux fasciocutanés pedicules à la jambe. In: Encyclopedia medicale,
chirugicale, techniques chirurgicale, et chirurgie reparatrice. Masson: Paris, 1986;4-11.
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Chapter 556
Flexor Digitorum Longus Muscle Flap
R. GER
EDITORIAL COMMENT
The editors emphasize the numerous contributions of Dr. Ralph Ger, who introduced the use of muscle as a
potential tissue for coverage of defects, particularly of bone devoid of periosteum. Modern reconstructive
plastic surgery has developed on his shoulders. The small muscles in the foot obviously provide limited
coverage for small defects and, in fact, have found limited application. The flexor digitorum longus muscle is
rarely used and usually only in association with the soleus muscle for small tibial defects.
The flexor digitorum longus, a modest-sized muscle, can be used to supplement other muscles, the soleus above
or the abductor hallucis below, when large defects require coverage. By itself, the muscle is ideal both for closing
small soft-tissue defects and for filling a small but deep osteomyelitic lesion. In the latter situation, larger muscles
are unsuitable, and using a small isolated portion of these muscles may be hazardous (1, 2, 3, 4, 5, 6, 7).
ANATOMY
Arising from the middle two fourths of the posteromedial surface of the tibia, the moderate-sized muscle belly
gives way to its tendon that runs along most of the posterior surface of the muscle. The tendon crosses the
tendon of the tibialis posterior behind the medial malleolus. The neurovascular supply from the posterior tibial
nerve and vessels reaches the muscle at the junction of the upper and middle thirds of the leg.
OPERATIVE TECHNIQUE
The muscle is easily exposed through a vertical incision placed 1 in (2.5 cm) behind the posterior border of the
subcutaneous surface of the tibia and running from the junction of the proximal and middle thirds of the leg to the
medial malleolus (Figs. 556.1, 556.2, 556.3). The long saphenous vein and saphenous nerves lie anterior to the
incision. The deep fascia is incised, and the muscle belly is recognized lying at a deeper level than the soleus
muscle. It is easiest to mobilize the muscle from below, where the tendon can be divided as it crosses the tendon
of the tibialis posterior. The distal part of the divided tendon can be sutured to the underlying tibialis posterior
tendon to retain a considerable portion of the muscle's function. An alternative method is to dissect the muscle
belly off its long tendon, leaving the latter intact.
CLINICAL RESULTS
Functional deficits are minimal. Presumably, the flexor digitorum brevis, the substantial slip from the flexor
hallucis longus as the latter is crossed by the tendon of the flexor digitorum longus, and the quadratus
plantae help to compensate for any functional loss.
SUMMARY
The flexor digitorum longus muscle can be used alone to cover small leg defects or in conjunction with other
muscles to cover larger defects.
FIGURE 556.1 The flexor digitorum longus occupying an excised ulcer bed, its tendon still intact. A
varicosed branch of the long saphenous vein has been removed through the small anterior incision.
FIGURE 556.2 The flexor digitorum muscle is seen lying anterior to the superficial calf muscles. The ulcer is
situated in the distal third of the anteromedial area of the leg. The line of incision is depicted by the dotted
outline.
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FIGURE 556.3 The mobilized muscle is rotated into the excised defect. The main neurovascular supply is
situated in the proximal third of the leg. The arrow indicates the posterior tibial vessels.
References
1. Ger R. The operative treatment of the advanced stasis ulcer: a preliminary communication. Am J Surg
1966;111:659.
2. Ger R. The management of pretibial skin loss. Surgery 1968;63:757.
3. Ger R. Operative treatment of the advanced stasis ulcer using muscle transposition: a follow-up study. Am
J Surg 1970;120:376.
4. Ger R. The technique of muscle transposition and the operative treatment of traumatic and ulcerative
lesions. J Trauma 1971;2:502.
5. Ger R. Surgical management of ulcerative lesions of the leg. Curr Probl Surg Mar 72:1.
6. Ger R. The management of stasis ulcers of the leg where the tendocalcaneous is exposed. Plast Reconstr
Surg 1977;60:337.
7. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis, Mosby,
1982;563.
Chapter 557
Abductor Digiti Minimi Muscle Flap
R. GER
EDITORIAL COMMENT
The usefulness of this flap is limited by the relative smallness of the muscle unit.
The abductor digiti minimi muscle is used to cover defects of the heel and the lateral surface of the ankle joint
and lower leg (1, 2, 3). Its posterior bulk is surprisingly large and considerably bigger than that of the abductor
hallucis.
ANATOMY
This muscle has a wide posterior origin from both processes (tubercles) and the intervening bone of the
calcaneus and the adjacent thick fascia (Figs. 557.1, 557.2 and see also Fig. 561.1 in Chapter 561). The wide
muscle belly narrows to a tendon near the base of the fifth metatarsal. The final insertion of the muscle is into the
lateral side of the proximal phalanx of the little toe, in common with the flexor digiti minimi brevis. Variations may
occur on the way to this insertion. The overlying thickened fascia, the calcaneometatarsal band or lateral cord
that inserts into the base of the fifth metatarsal, may contain muscle fibers and constitute the abductor metatarsi
quinti. Sometimes, there are two separate muscle bellies that stop and start opposite the base of the fifth
metatarsal. The neurovascular supply from the lateral plantar nerve and vessels enters the muscle well toward
its origin.
OPERATIVE TECHNIQUE
This muscle is exposed by an incision just above the lateral border of the foot that runs from the heel to the head
of the fifth metatarsal. The tendon is divided near its insertion, and the muscle is dissected proximally where it
requires separation from the flexor digiti minimi brevis. The lateral plantar vessels and nerves lie well to the
medial border of the muscle between it and the flexor digitorum brevis (Fig. 557.3).
Because the main vessels and nerve enter the muscle from the medial side, the dissection should first proceed
along the lateral border of the muscle to its calcaneal origin. Along the medial border of the muscle, dissection
proceeds until the neurovascular bundle is identified. The muscle can be maximally mobilized by severing its
broad calcaneal origin and leaving it attached by its neurovascular pedicle only (Fig. 557.4).
CLINICAL RESULTS
Intrinsic muscles of the sole of the foot are concerned mostly with the maintenance of the longitudinal or
transverse arches. The functional deficiency following loss of this muscle is not clinically discernible.
SUMMARY
The abductor digiti minimi muscle can be separated from both its origin and its insertion and used to cover
defects of the heel and lateral ankle.
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FIGURE 557.1 A: The flexor digitorum brevis (fd) is flanked by the abductor digiti minimi (ad) and abductor
hallucis (ah) muscles. Note the double insertion of the abductor digiti minimi into the base of the fifth
metatarsus and into the proximal phalanx of the fifth toe. The digital vessels and nerves are well seen. B:
Coronal section of the ankle joint showing the relative sizes of the abductor digiti minimi and abductor
hallucis muscles near their origins. (From Ger, ref. 1, with permission.)
FIGURE 557.2 A: The abductor digiti minimi with its vascular supply. An ulcer of the heel is excised as
depicted by the oval dotted outline. The longitudinal dotted line exposes the muscle. The abductor digiti
minimi tendon is dissected free from the adjoining flexor digiti minimi brevis tendon and muscle (arrow). B:
The muscle is rotated superiorly without disturbing its bony origin. C: The muscle is rotated superiorly with
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partial separation of its bony origin. D: The muscle is completely detached from its broad origin for maximal
mobilization. E: The muscle occupies and is sutured to the edges of the defect.
FIGURE 557.3 The abductor digiti minimi is dissected free, its distal tendon having been severed. The
extensor digitorum brevis is seen lying in situ.
FIGURE 557.4 The muscle is occupying an excised heel defect prior to skin-graft application.
References
1. Ger R. The surgical management of ulcers of the heel. Surg Gynecol Obstet 1975;140:909.
2. Ger R. The management of chronic ulcers of the dorsum of the foot by muscle transposition and free skin
grafting. Br J Plast Surg 1976;29:199.
3. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982.
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Chapter 558
Abductor Hallucis Brevis Muscle Flap
R. GER
This muscle can be used to cover defects over the heel and medial aspect of the ankle joint and medial
malleolus (1, 2, 3, 4, 5, 6). In combination with other muscles, it also can be used to cover defects of the dorsum
of the foot and lower end of the tibial shaft.
ANATOMY
The abductor hallucis arises from the medial process (tubercle) of the calcaneus and the surrounding fascia. The
fleshy belly gives rise to a tendon at about the midfoot (medial cuneiform-first metatarsal articulation) that inserts
into the medial side of the proximal phalanx of the big toe in common with the tendon of the medial portion of the
flexor hallucis brevis. The neurovascular supply from the medial plantar nerve and vessels arises proximally
about two to three fingerbreadths behind the navicular tuberosity (Fig. 558.1; also Figs. 50.1 and 50.2A, Chapter
50; Fig. 559.1A, Chapter 559; and Fig. 560.4, Chapter 560.)
OPERATIVE TECHNIQUE
The muscle is exposed by an incision that lies just above the medial border of the sole of the foot and curves
from the heel to the ball of the big toe (Fig. 558.2). The tendon is divided proximal to the metatarsophalangeal
joint and dissected proximally. It is usually possible to separate the tendon from the adjacent flexor hallucis
brevis, but sometimes the tendon and muscle of the abductor fuse with the flexor hallucis brevis and sharp
dissection is required.
FIGURE 558.1 The abductor hallucis (ah) with the medial plantar neurovascular structures and the tendon of the
flexor hallucis longus (fl) on its medial side. The abductor digiti minimi (ad) on the lateral aspect of the foot. The
flexor digitorum longus tendon (fd) and the lateral plantar nerve (n) are running mediolaterally across the sole of
the foot. The flexor hallucis brevis (fb), flexor digiti minimi brevis (fdm), plantar accessories (pa), and lumbrical (l)
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muscles are also seen. (Dissections performed by A. DiLandro.)
FIGURE 558.2 A: The abductor hallucis and its blood supply. The line of incision for exposure is indicated, and
a medial malleolar ulcer is depicted. B: The muscle has been divided at its tendinous junction and is about to be
rotated into the defect created by the excised ulcer. C: The muscle is sutured to the skin edges of the excised
defect.
Because the neuromuscular bundle enters from the lateral side, the medial border of the muscle is first mobilized
until the calcaneal origin is reached. The lateral border is then immobilized until the neurovascular bundle is
located. As in the case of the abductor digiti minimi, the muscle can be stripped off the calcaneus, depending on
the amount of mobilization required (Fig. 558.3).
CLINICAL RESULTS
Functional deficits are not clinically apparent. The muscle is a supporter of the medial longitudinal arch, and
it would seem that the numerous other supporting structures of this arch are sufficient to compensate for
loss of this muscle.
SUMMARY
The abductor hallucis muscle can be used to cover defects from the heel to the area of the medial
malleolus. Used with other muscles, it can cover defects of the dorsum of the foot and ankle.
FIGURE 558.3 The mobilized abductor hallucis is rotated superiorly to cover an underlying defect.
References
1. Ger R. The management of pretibial skin loss. Surgery 1968;63:757.
2. Ger R. Operative treatment of the advanced stasis ulcer using muscle transposition: A follow-up study. Am
J Surg 1970; 120:376.
3. Ger R. The technique of muscle transposition and the operative treatment of traumatic and ulcerative
lesions. J Trauma 1971;2:502.
4. Ger R. The surgical management of ulcer of the heel. Surg Gynecol Obstet 1975;140:909.
5. Ger R. The management of chronic ulcers of the dorsum of the foot by muscle transposition and free skin
grafting. Br J Plast Surg 1976;29:199.
6. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982;594.9
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Chapter 559
Flexor Digitorum Brevis Muscle Flap
R. GER
The flexor digitorum brevis muscle is used exclusively to cover defects of the heel (1, 2, 3).
ANATOMY
This muscle has a relatively narrow origin from the medial process (tubercle) of the calcaneum but a substantial
origin from the plantar aponeurosis. The belly gives rise to four tendons just beyond the metatarsophalangeal
joints that run deep to the divisions of the plantar aponeurosis. Opposite the bases of the proximal phalanges,
the tendons split to allow the passage of the tendons of the flexor digitorum longus and then insert into the sides
of the middle phalanges. The neurovascular bundles to the digits and the lumbricals run between the tendons.
The muscle is covered by the thick plantar aponeurosis and is flanked by the abductors hallucis and digiti minimi
muscles. The neurovascular supply to the muscle arises proximally from the lateral plantar nerve and vessels as
they pass laterally deep to the muscle (see Fig. 559.1A).
FIGURE 559.1 A: The flexor digitorum brevis and the abductor hallucis muscles are depicted with the medial
plantar vessels between them. The oval dotted line indicates the excised heel ulcer, and the longitudinal dotted
line indicates the incision required to expose the flexor digitorum brevis. The transverse dotted line indicates the
division at the muscles and tendinous junctions. B: The muscle belly is turned on itself to cover the heel defect.
OPERATIVE TECHNIQUE
The muscle is exposed by a midline incision on the plantar aspect of the foot (Fig. 559.1 and see Fig. 557.1 in
Chapter 557). The plantar aponeurosis is incised and reflected medially and laterally, and the muscle is identified
deep to the fascia. The musculotendinous junctions are severed, and the muscle is turned back on itself
proximally (Fig. 559.1). Mobilization proceeds until the muscle covers the calcaneus, taking care not to injure the
underlying lateral plantar nerve and vessels.
CLINICAL RESULTS
Functional deficits are not seen, since the flexor digitorum longus flexes the joints of the toes.
SUMMARY
The flexor digitorum brevis muscle can be used to cover heel defects.
References
1. Bostwick J III. Reconstruction of the heel pad by muscle transposition and split-skin graft. Surg Gynecol
Obstet 1976;143:972.
2. Hartrampf CR Jr, Scheflan M, Bostwick J III. The flexor digitorum brevis muscle island pedicle flap: A new
dimension in heel reconstruction. Plast Reconstr Surg 1980;66:264.
3. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982;598.
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Chapter 560
Flexor Hallucis Brevis Muscle Flap
R. GER
The medial portion of the flexor hallucis brevis is suitable for use in conjunction with the abductor hallucis for
lesions of the dorsum of the foot (1, 2, 3, 4, 5). The whole muscle can be used by itself to fill defects in the
anteromedial sole of the foot, such as perforating ulcers (mal perforans).
ANATOMY
This muscle arises by a pointed tendon from the contiguous surfaces of the plantar surface of the cuboid and
medial cuneiform. Medial and lateral portions of the muscle develop and
insert into either side of the base of the proximal phalanx of the big toe, a sesamoid bone developing in each
tendon and articulating with the head of the first metatarsal. Each portion is joined by another tendon of insertion,
the medial by that of the abductor hallucis and the lateral by the adductor hallucis. The tendon of the flexor
hallucis longus straps the muscle belly down to the first metatarsal (Fig. 560.1). The nerve supply from the first
digital nerve enters the muscle near its origin. The blood supply is from the medial plantar and first plantar
metatarsal vessels.
FIGURE 560.1 The two portions of the flexor hallucis brevis (fb) can be seen; the medial portion is joined by the
distal portion of the abductor hallucis (arrow). The lumbricals (l) and the abductor digiti minimi (ad) are also seen.
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FIGURE 560.2 A: The conjoint medial portion of the flexor hallucis brevis and abductor hallucis muscles has
been exposed through an incision along the medial border of the sole of the foot and is being rotated onto the
dorsum of the foot to cover an ulcer. The lateral portion of the flexor hallucis brevis is in situ (arrow). B: The
muscles are occupying the defect. Depending on the proximity of the ulcer to the incision, the latter can be
placed to include the medial border of the ulcer or it can be placed some distance away. Wherever placed, a
narrow skin bridge between the ulcer and the incision should be avoided.
OPERATIVE TECHNIQUE
The incision is the distal portion of that used for exposing the abductor hallucis. The muscle is easily recognized
as it lies against the plantar aspect of the first metatarsal. Either the medial portion or the whole muscle can be
used. The medial portion can be used in conjunction with the abductor hallucis (Figs. 560.2 and 560.3). In this
instance, the conjoint tendon of insertion into the medial side of the first phalanx is divided, and the muscles are
mobilized proximally. Because the flexor hallucis longus tendon lies on the middle of the muscle, it demarcates
each portion. It is therefore simple to split the muscle along the line of the tendon. Both the medial portion and
the abductor hallucis are reflected proximally as far as necessary. If the whole muscle is to be used, it is
detached at its origin and mobilized distally, reflecting the tendon of the flexor hallucis longus laterally to facilitate
this dissection. During this dissection, the nerve supply to the muscle is sacrificed (Fig. 560.4).
FIGURE 560.3 The mobilized abductor hallucis and flexor hallucis brevis muscles rotated on themselves to fill a
plantar defect. At this level, the abductor hallucis is represented by its tendon only (arrow).
FIGURE 560.4 A: The mobilized abductor digiti minimi (adm) and conjoined abductor hallucis and flexor hallucis
brevis muscles (ah). The extensor digitorum brevis (eb) is undisturbed. The ulcer over the anterior aspect of the
ankle joint is depicted as well as the lines of excision. B: The abductors have been rotated into the defect. The
extensor digitorum brevis does not require mobilization.
CLINICAL RESULTS
There are no discernible functional deficits, as the flexor hallucis longus will flex the metatarsophalangeal
joint.
SUMMARY
The flexor hallucis brevis muscle can be used in its entirety for anteromedial defects. The medial portion
can be used with the abductor hallucis brevis for dorsal foot defects.
References
1. Ger R. The management of pretibial skin loss. Surgery 1968;63:757.
2. Ger R. Operative treatment of the advanced stasis ulcer using muscle transposition: A follow-up study. Am
J Surg 1970;120:376.
3. Ger R. The technique of muscle transposition and the operative treatment of traumatic and ulcerative
lesions. J Trauma 1971;2:502.
4. Ger R. The management of chronic ulcers of the dorsum of the foot by muscle transposition and free skin
grafting. Br J Plast Surg 1976;29:199.
5. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982;594.
Chapter 561
Extensor Digitorum Brevis Muscle Flap
R. GER
EDITORIAL COMMENT
This muscle should be thought of for relatively small defects on the dorsum of the foot.
The extensor digitorum brevis is not of great use because of its limited mobility. Nevertheless, at times it may be
used to cover a defect in the region of the lateral malleolus and anterior ankle.
ANATOMY
This small muscle arises mainly from a small anterior area of the lateral surface of the calcaneus close to the
calcaneocuboid articulation. The muscle belly runs forward and medially to end in four tendons at the level of the
tarsometatarsal joints. The three lateral tendons join and insert with the tendons of the extensor digitorum longus
to the lateral three toes. The most medial tendon is sometimes called the extensor hallucis brevis, because it
forms a somewhat distinct slip and inserts into the base of the proximal phalanx of the big toe. The vascular
supply is a branch of the lateral tarsal artery that arises from the dorsalis pedis, enters the deep surface of the
muscle, and then anastomoses with several other arteries (see Fig. 561.1A).
FIGURE 561.1 A: Extensor digitorum brevis muscle supplied by branches of the dorsalis pedis vessels. The
curved dorsal incision over the lateral part of the muscle is indicated by the dotted line. Distally, the transverse
dotted line marks the division of the muscle at the musculotendinous junctions. B: The muscle is reversed on
itself to cover the excised ulcer over the lateral malleolus.
OPERATIVE TECHNIQUE
The muscle can be exposed by a curved incision that is placed over the muscle and runs from just below the
crease of the ankle for approximately 4 in (10 cm) (Fig. 561.1 and see Fig. 557.3 in Chapter 557). The four
tendons are divided, and the muscle is reversed on itself.
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CLINICAL RESULTS
Functional deficits are minimal, since the extensors hallucis and digitorum longus are more effective
extensors.
SUMMARY
The extensor digitorum brevis can sometimes be used to cover defects around the lateral malleolus.
Chapter 562
Flexor Hallucis Brevis Muscle Flap
K. T. MAHAN
EDITORIAL COMMENT
This is a good flap for coverage of plantar ulcerations, if the muscle is still viable.
The flexor hallucis brevis muscle flap can be particularly useful for providing muscle coverage below the first
metatarsal head. This flap, as well as other intrinsic muscle flaps of the foot, rotated and used to provide muscle
coverage, is limited in its coverage area by a small arc of rotation (1, 2, 3, 4, 5).
INDICATIONS
The flexor hallucis brevis flap can be used for managing ulcerations on the plantar and medial sides of the
foot. The flap is not a first choice of treatment, but can be used when ulcers fail to respond to conservative
therapy. The procedure involves excision of the ulcer, filling the defect with the muscle, and applying a split-
thickness skin graft over the muscle, as necessary. The most common indication is sub first metatarsal-
head ulceration. This frequently occurs in conjunction with neuropathy associated with diabetes mellitus.
ANATOMY
The flexor hallucis brevis has a Y-shaped fibrotendinous origin within the foot. A medial component originates
from the tendon of the tibialis posterior and the medial cuneiform. The lateral origin begins on the lateral side of
the foot, including the lateral cuneiform and cuboid, the peroneal tendons, and the short and long bifurcate
ligaments. The body of the muscle then runs beneath the first metatarsal, where, distally, it divides into medial
and lateral heads. The lateral head inserts on the plantar plate, the medial aspect of the fibular sesamoid, and
the base of the proximal phalanx, where it joins with the fibers of the adductor hallucis. The medial head is
somewhat larger and inserts on the medial aspect of the plantar plate and on the lateral aspect of the tibial
sesamoid, as well as on the base of the proximal phalanx medially, in conjunction with fibers from the abductor
hallucis.
Muscle innervation comes from the first proper digital nerve of the big toe, a branch of the medial plantar nerve.
The vascular supply comes from the first plantar metatarsal artery, forming from the junction of the lateral and
deep plantar arteries. It generally enters from the lateral side of the muscle in the mid-body region.
OPERATIVE TECHNIQUE
The incisional approach is from the plantar aspect of the foot, in order to have full and complete visualization of
the flexor hallucis brevis. This can be done through a straight linear incision or a zig-zag anti-tension line
approach (Fig. 562.1). An incision is made in the deep fascia, and the tendon of the flexor hallucis longus is
retracted laterally. From this point forward, the approach will depend on whether the surgeon wishes to rotate the
flap proximally or distally. Bone resection may be necessary if there is underlying osteomyelitis or exostoses.
The sequence of events for distal rotation follows. The incisional approach is made back into the mid-foot area,
in order to identify the origins of the flexor hallucis brevis. These are sharply transected, and the muscle flap is
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lifted gently and
reflected distally (Fig. 562.2). Care must be taken to ensure that the muscular artery is initially preserved. If the
arc of rotation allows for enough muscle to fill the sub first metatarsal space, then the divided origins of the
muscle are sutured into place on the plantar plate. If there is inadequate rotation, a muscular artery can be
divided and the flap rotated far more distally. In either event, the flap can be sutured into place, and the incisional
approach closed or covered with a skin graft. This reduces the mechanical effects caused by bone protrusion, as
well as providing additional space for the muscle flap. Another alternative is for the skin to be closed primarily
over the muscle flap, although this can create excessive tension (Fig. 562.3).
FIGURE 562.1 A sub first metatarsal ulceration in a diabetic patient. Note zig-zag anti-tension line approach.
(From Mahan, Feehery, ref. 5, with permission.)
FIGURE 562.2 Detachment of the origins of the flexor hallucis brevis and pivoting of muscle on its arc of rotation.
(From Mahan, Feehery, ref. 5, with permission.)
FIGURE 562.3 Plantar aspect of the foot 3 weeks postoperatively, demonstrating superficial dehiscence caused
by tension of the primary closure. Nonetheless, the wound went on to complete healing and has not broken
down since the time of surgery, about 6 years previously. (From Mahan, Feehery, ref. 5, with permission.)
CLINICAL RESULTS
Postoperatively, the patient is managed in non-weight-bearing in a posterior splint for approximately 3
weeks. Return to weight-bearing begins at this point, with partial weight allowed. Neuropathic patients are
graduated to full weight-bearing more slowly.
A caveat is that, if the mechanical imbalances in the foot have not been addressed, the flap will ultimately
fail. For example, a diabetic neuropathic patient who has a plantar-flexion deformity of the first metatarsal is
likely to have ulceration through the muscle flap. Care should be taken to rebalance the foot with an orthotic
or shoe modification. Some loss of hallux purchase will occur with the sacrifice of the flexor hallucis brevis.
This is not too important in apropulsive patients, such as neuropathic diabetics. Additional stabilization can
be created by suturing the plantar plate and flexor hallucis brevis tendons to the flexor hallucis longus.
The flexor hallucis brevis muscle flap has a limited, but important, role in the management of ulcerations in
the foot. Because of foot mechanics, the first metatarsal area is a common site for ulceration. Patients who
have been resistant to conservative therapy respond well to this muscle flap as a permanent form of
coverage.
SUMMARY
The flexor hallucis brevis muscle flap is useful for ulcerations beneath the first metatarsal. It has a limited
arc of rotation and one primary blood supply.
References
1. Weaver J, Porter MC. Surgical repair of the foot with muscle transposition. JAPMA 1988;78:254.
2. Ger R. The surgical management of ulcers of the heel. Surg Gynecol Obstet 1975;140:909.
3. Ger R. Newer concepts in the surgical management of lesions of the foot in a patient with diabetes. Surg
Gynecol Obstet 1984;158:213.
4. Ger R. Muscle transposition in the management of perforating ulcers of the forefoot. Clin Orthop
1983;175:186.
5. Mahan KT, Feehery RV. Flexor hallucis brevis muscle flap. J Foot Surg 1991;30:284.
Chapter 563
Cross-Foot Skin Flap
G. A. TAYLOR
EDITORIAL COMMENT
The advantage of this procedure is that it provides the same type and quality of skin as was lost. It is most
likely that this type of coverage will be longer lasting. Cross-thigh flaps and cross-leg flaps are still
procedures to be reckoned with, even in this day of microvascular free- tissue transfers. The indications
should be limited to younger people, probably below the age of 40, because of the need for immobilization
in peculiar flexed positions. Current immobilization techniques make use of external fixators rather than
plaster immobilization, which is bulkier and more uncomfortable for the patient.
Reconstruction of the weight-bearing portion of the plantar surface of the foot is an ongoing challenge to the
ingenuity of the plastic surgeon (1).
INDICATIONS
The cross-foot flap may be used for reconstruction of weight-bearing and friction-bearing plantar skin
defects up to 5 × 8 cm. The contralateral instep donor site provides histologically similar skin.
ANATOMY
The cross-foot flap (2, 3), as a “functional graft of the heel,” is a random-pattern flap of the distant direct type (4)
raised from the plantar instep of the contralateral foot. The plantar skin differs significantly from the skin of the
other parts of the body. The epidermis is much thicker (up to 1.4 mm) and consists of well-defined classic layers
of stratum corneum through stratum germinativum, with the former particularly well developed. Pigment cells are
rare, and sebaceous glands and hair follicles are absent. The dermis is thicker (up to 3 mm), with more regularly
aligned collagen bundles and less ground substance (5). The extension of the collagen bundles into the subcutis
and plantar fascia binds the plantar skin to the skeleton for traction, at the same time producing a “shock-
absorbing” system of closed fat loculations. These characteristics are best developed over the metatarsal heads,
the heel, and the lateral aspect of the sole (the weight-bearing region), and gradually fade out toward the
periphery.
Although not so distinctive as in the weight-bearing areas, these features are still well developed in the non-
weight- bearing or instep portion of the sole of the foot (Fig. 563.1). The instep skin is supplied by two branches
of the medial plantar artery that perforate on either side of the underlying abductor hallucis muscle and by small
perforating vessels that represent the musculocutaneous circulation through that muscle (6).
FLAP DESIGN AND DIMENSIONS
A random-pattern flap of skin can be raised from this area without a delay procedure and without encountering
circulation problems if the following guidelines are followed (Figs. 563.1 and 563.2). The flap can be up to 5 × 8
cm large and based either medially or laterally depending on the size, shape, and location of the defect to be
covered on the affected foot.
Preoperative planning should be done with the patient supine in bed to ensure a comfortable leg position. The
feet may be positioned parallel or at 90 degrees to one another.
OPERATIVE TECHNIQUE
The defect is patterned and the flap is designed and marked according to the preoperative plan. The flap is
raised in the natural plane of dissection deep to the subcutaneous tissue, and the defect is covered with a split-
thickness skin graft, usually taken from the opposite instep and secured with a tieover dressing (Fig. 563.3).
After the flap is sutured in place, leg fixation is applied using Elastoplast, flannel bandage, plaster of Paris, or
threaded Steinmann pins transfixing the tibiae. Postoperatively, the patients' knees and hips usually can be
moved through a reasonable range of motion without disturbing the flap.
The pedicle is divided in 2 to 3 weeks without a definitive insetting procedure. Ambulation is begun without
weight bearing at 3 to 4 weeks, with weight bearing commencing at 4 to 5 weeks (7).
FIGURE 563.1 (Left) The donor area for a cross-instep flap. (Center) The flap is outlined on the instep of the
donor foot using a pattern and raised, applying a split-thickness skin graft to the donor defect. (Right) The feet
can be placed either parallel (above) or at 90 degrees (below) when the flap is sutured in place. (From Taylor,
Hopson, ref. 7, with permission.)
CLINICAL RESULTS
The largest reported experience with the use of this flap has been 16 patients, with no problems in the
reconstructed foot and only one troublesome donor-site scar that was excised secondarily (3). Recently, a
cross-foot flap using an arterialized dorsalis pedis flap from the dorsum of the foot for coverage of defects of
the opposite lateral malleolus was described (8).
FIGURE 563.2 A: A 37-year-old woman with a full-thickness defect on her posterior heel from a tight cast
applied for a fractured medial malleolus. Preoperative hyperkeratotic scar on the right heel. B:
Postoperatively, the patient has a soft and completely healed and stable skin flap, with no evidence of
hyperkeratosis. (From Taylor, Hopson, ref. 7, with permission.)
SUMMARY
The cross-foot skin flap replaces pressure-bearing skin with histologically similar skin. The cross-foot
position is a comfortable one, and the donor site is particularly inconspicuous.
FIGURE 563.3 A: Preoperatively, there was a persistent ulcer on the weight-bearing prominence of the os
calcis. This patient had sustained a severe crush and avulsion injury of his right foot 7 to 10 years
previously when it was caught beneath the wheel of a train. The defect had been repaired with a
combination of full- and split-thickness skin grafts. B: The well-padded recipient area has remained healed
postoperatively. (From Taylor, Hopson, ref 7, with permission.) C: The donor site on the opposite instep
postoperatively.
References
1. Sommerlad BC, McGrouther DA. Resurfacing the sole: long-term follow- up and comparison of techniques.
Br J Plast Surg 1973;31:107.
2. Mir y Mir L. Functional graft of the heel. Plast Reconstr Surg 1954;14:444.
3. Mir y Mir L. Follow-up clinic. Plast Reconstr Surg 1975;55:702.
4. Grabb WC, Myers MB eds. Skin flaps. Boston: Little, Brown, 1975;145, 151.
5. Bloom W, Fawcett DW eds. A textbook of histology, 9th ed. Philadelphia: Saunders, 1968.
6. Harrison DH, Morgan DG. The instep island flap to resurface plantar defects. Br J Plast Surg
1981;34:315.
7. Taylor GA, Hopson WL. The cross-foot flap. Plast Reconstr Surg 1975;55:677.
8. Cervino AL, Thottam H. Cross-foot flap for ankle coverage. Ann Plast Surg 1979;2:72.
Chapter 564
Cross-Thigh Flap
H. TRAMIER
The fragility and lack of mobility of the skin and subcutaneous tissue of the leg and foot make skin defects in this
region especially serious. In many cases, flap coverage from a distance is required.
The cross-leg flap has been used since the nineteenth century; however, surgeons soon became aware that the
posterior part of the leg, a rather narrow area used most commonly for this flap, had very fragile circulation. The
flap also resulted in prolonged discomfort for patients (1). It became evident that there was a need for using other
territories of the leg as donor sites.
INDICATIONS
There are problems involved in using the cross-thigh flap (2, 3, 4, 5, 6, 7, 8, 9). The flap is contraindicated
for older patients and those without supple joints. The sensory requirements of the recipient defect must be
taken into account. The thinner the flap, the better the return of sensation.
ANATOMY
The vascular system of the skin of the lower leg is apparently different above and below the knee (10). The skin
below the knee is vascularized mainly by the perforating arteries coming from the deep trunk, each one providing
the nutritional supply of an important cutaneous area. Normally, small anastomoses exist between the larger
vessels, but generally they are insufficient to compensate for the loss of several perforating arteries. Delaying
the flap will allow the development of small anastomoses, but their state will remain precarious. Venous drainage
of the lower limb is ensured principally by the two large longitudinal saphenous veins, at least one of which must
remain intact (11).
The thigh, however, is supplied by arteries that are long and large, although few. Large-diameter subdermal
anastomoses are especially scarce in the inferolateral third of the thigh, although dermal anastomoses are
numerous in the anterior and medial areas and in a band of tissue separating the posterior and lateral regions.
In the anterior thigh, a wealth of large transverse vessels permits a certain amount of undermining without risk,
except in the upper area. Transecting large vessels presents little drawback because of the number of
subdermal and dermal anastomoses. In the lateral region, large arteries are scarce, the subdermal anastomotic
network is rich, and the dermal network less so. Undermining at this level causes few problems if it is not too
extensive.
Posteriorly, the upper half possesses long, large arteries with numerous anastomoses. In the lower half,
however, the arteries are shorter and thinner with poor subdermal anastomoses. Superficial venous drainage is
provided by a rich subcutaneous network. Thus, the good cutaneous vascularity of the thigh provides the best
donor site for taking a flap from the lower limb.
FLAP DESIGN AND DIMENSIONS
Once the exact extent of the defect is determined, the flap size, donor site, and orientation must be carefully
designed (11). Gillies advised sitting on the floor beside the patient to find the best position and the ideal “cross-
leg.” This notion is still valid in determining the best flap location and the best position for the lower limbs (Fig.
P.1531
564.1).
OPERATIVE TECHNIQUE
First Stage (Delay)
Depending on the length of the skin defect redrawn on the thigh, the flap is extended by the distance separating
the donor site from the recipient site—at least 2 cm. Three sides of the flap are cut, including the superficial
fascia of the thigh. The flap is then sutured in place.
FIGURE 564.1 The cross-thigh flap can easily be designed to cover ankle and foot defects.
Second Stage (Flap Transfer)
On the eighth day, the flap is transferred. After the defect is prepared, the thigh flap is elevated and sutured in
place. Elasticized tape is used to immobilize the legs in the correct position (Fig. 564.2).
FIGURE 564.2 A: Defects of both the heel and lateral surface of the foot outlined. B: Just prior to stage III
(division of the pedicle). The elasticized tape used to immobilize the legs has been removed. C: Postoperative
result.
P.1532
Third Stage (Pedicle Division)
This is performed after 2 weeks of immobilization and involves cutting the pedicle from the flap, which has been
thickened by edema.
Fourth Stage (Insetting)
The flap is inset a week later. The donor site is grafted either at this point or earlier during the second stage. The
flap margin is trimmed and sutured without tension to the remaining edge of the defect.
Variations in Shape
By changing the position of the two limbs as well as the direction of the flap and the location of its pedicle, all the
skin of the thigh can be used without difficulty. As many different techniques as patients may be imagined. Two
simultaneous flaps can be used in various combinations to cover one or more defects on the leg or foot (9).
CLINICAL RESULTS
The good vascularity of the thigh as well as the proper surgical precautions reduce the risk of flap necrosis.
Small pressure
sores may appear on the donor thigh in patients who are not well supported, but they are of little
consequence because of the thickness of the muscles of the anterior part of the thigh. A simple excision of
the injured tissues solves this problem. The position may not be tolerated, especially by obese patients.
SUMMARY
The cross-thigh flap is a reliable technique that gives the patient little discomfort. It provides an important
source of tissue for covering skin defects of the leg and foot. More than one skin flap can be used
simultaneously.
References
1. Ombredanne L, Jeambrau E, Nove-Josserand P. Chirurgie reparatrice et orthopedique. Paris: Masson,
1920;97-100.
2. Pierre M, Jouglard JP. La réparation des pertes de substance de la plante du pied. Marseilles Chir
1966;00:328.
3. Mladick RA, Pickrell KL, Thome FL, Royer JR. Ipsilateral thigh flap for total plantar resurfacing. Plast
Reconstr Surg 1969;43:198.
4. Tramier H. Les pertes de substances traumatiques de la plante du pied: Approche anatomo-chirurgicale.
Prix Acad Med 1969.
5. Tramier H, Jouglard JP. Le “cross-thigh flap”: une interessante source de tissu dans la chirurgie du pied.
Ann Chir Plast 1976;21:285.
6. Fumas DW. The cross-groin flap for coverage of foot and ankle defects in children: case report. Plast
Reconstr Surg 1976;57:246.
7. Wexler MR, Abu-Dalu X, Rousso M. The lotus position: bilateral crossthigh flap for simultaneous coverage
of both feet. Plast Reconstr Surg 1978;61:784.
8. Drabyn GH, Avedian L. Ipsilateral buttock flap for coverage of a foot and ankle defect in a young child.
Plast Reconstr Surg 1979;63:422.
9. Di Piro EM, Moser MH. Cross-thigh flap for bimalleolar defect. Plast Reconstr Surg 1979;44:91.
10. Salmon M. Artères de la peau. Paris: Masson, 1936.
11. Goumain AJM, Pellegris M, Scnegas J. Technique des autoplastics cutanées jambières par lambeau
hétérolateral. Rev Chir Orthop 1969; 55:131.
Chapter 565
Cross-Groin Skin Flap
D. W. FURNAS
EDITORIAL COMMENT
Although this procedure is meritorious for keeping the scar hidden in the groin crease, the extreme nature of
the flexion and long period of immobilization required would reserve this procedure for those situations in
which a free-tissue transfer cannot be accomplished.
The cross-groin skin flap is an excellent means of gaining coverage of defects of the foot and ankle area in
children (1). The child's short lower limbs and supple joints make this pedicle sequence possible.
INDICATIONS
The ease with which children tolerate the cross-leg flap has been previously reported (2) (Fig. 565.1). The
groin flap offers more tissue than either a cross-leg flap or a cross-thigh flap, and the donor defect is much
easier to handle, particularly when it can be closed directly (3). In a child, the positioning and immobilization
for a cross-groin flap are no more difficult than for a cross-thigh flap. A cross-groin flap is probably not
useful for defects that are any appreciable distance above the ankle, but the flap is an excellent means for
covering soft- tissue defects of the distal portion of the lower limb in children.
FIGURE 565.1 Cross-groin flap in position on ankle defect. (The position can be maintained by plaster of
Paris, a Hoffman device, or bone screws and a custom-made acrylic bar.) (From Furnas, ref. 1, with
permission.)
OPERATIVE TECHNIQUE
McGregor's landmarks are used to design the flap (4, 5), and a Doppler probe is used to verify the position of the
superficial circumflex iliac artery. The Doppler probe is also used in monitoring the delay incisions for expeditious
separation of the flap (6) (Figs. 565.2 and 565.3).
SUMMARY
The cross-groin skin flap is useful for covering soft tissue defects of the distal portion of the lower limb in a
child.
FIGURE 565.2 A: A 7.5 × 15-cm avulsion-abrasion injury that destroyed the skin, tendons, joint capsule,
and bone, exposing the ankle and tarsal joints, in a 6-year-old girl. Segments of the peroneal and the
extensor digitorum communis tendons were lost. B: The cross-groin flap, 8 × 16 cm, elevated and ready for
transfer. The distal edge of the flap was halfway between the anterior superior iliac spine and the posterior
superior iliac spine. The donor site and the raw surface of the flap were covered with split-thickness skin
grafts. The flap was divided and inset on the 12th postoperative day after several preliminary delay
incisions. These incisions were made at the site that had the most prominent Doppler signal. C: The flap 5
months postoperatively. Two months after the injury, the child could walk with a barely perceptible limp;
however, a progressing eversion of her foot necessitated an extensor hallucis longus transfer, with a split
tibialis transfer. (From Furnas, ref. 1, with permission.)
FIGURE 565.3 A: This 6-year-old boy with a meningomyelocele was confined to a wheelchair. He had a left
clubfoot with a cicatricial deformity secondary to complications from previous foot surgery, which resulted in
a severe adduction contracture of the midfoot that prevented him from walking with braces. Surgical release
of the adduction deformity was planned by the orthopedists. A cross-groin flap was plotted for closure of the
resulting defect. B: At surgery, the adduction contracture of the foot was released and the foot was secured
with pins. (Continued)
FIGURE 565.3 (Continued) C: A right groin flap, 7 cm wide and 15 cm long, was elevated and tubed.
Woodruff screws were inserted into the right iliac crest and into the tibia. D: The defect of the foot was held
in apposition to the pedicle while an acrylic bar was fashioned to form a bridge between the iliac screws and
the groin screws. The flap was then sutured into position. E: Serial delay incisions were carried out, guided
by the Doppler arterial signal, and on the 12th postoperative day, the pedicle was divided and the acrylic
bridge and screws were removed. On the 14th day, final inset of the flap was carried out. This view shows
the patient 3 months after surgery, when he was fitted for braces and began training with them.
References
1. Furnas DW. The cross-groin flap for coverage of foot and ankle defects in children. Plast Reconstr Surg
1976;57:246.
2. Argamaso RV, Lewin ML, Baird AD, et al. Cross-leg flaps in children. Plast Reconstr Surg 1973;51:662.
3. Harii K, Ohmori K. Free groin flaps in children. Plast Reconstr Surg 1975;55:588.
4. McGregor I, Jackson I. The groin flap. Br J Plast Surg 1972;25:3.
5. Smith PJ, Foley B, McGregor IA, Jackson IT. The anatomic basis of the groin flap. Plast Reconstr Surg
1972;49:41.
6. Karkowski J, Buncke HJ. Simplified technique for free transfer of groin flaps by use of a Doppler probe.
Plast Reconstr Surg 1975;55:682.
Chapter 566
Buttock Skin Flap
G. A. DRABYN
J. F. NAPPI
EDITORIAL COMMENT
See comment accompanying Chapter 565, which applies even more drastically here.
Reconstruction of ankle and foot defects with exposure of deep structures has required major and complicated
procedures to secure adequate coverage and a functional limb. Cross-leg flaps were the standard form of
coverage until the advent of free composite-tissue transfer. Anyone who has done cross-leg flaps is well aware
of the magnitude of potential complications (1, 2). In children, the postural restrictions often result in anxiety and
fear, and free flaps in children are often difficult undertakings. Many of these drawbacks can be avoided by the
use of an ipsilateral extremity flap (3, 4, 5, 6). It has been our preference to use the ipsilateral buttock flap to
resurface ankle and foot defects in children (7).
INDICATIONS
The ipsilateral buttock flap offers several advantages over the cross-leg flap in a child. (1) Size: this is an
extremely large random-pattern flap. (2) Protection: the flap offers adequate soft tissue for padding and
bulk. (3) Comfort: the patient is immobilized in a position of relative comfort and may ambulate with crutches
a few days postoperatively. (4) Ipsilaterality: there is avoidance of potential complications with the normal
leg. (5) Donor site: the scars are well hidden, and unsightly scars on the opposite leg are avoided. (6)
Anxiety: children are much less prone to anxiety with fewer postural restrictions.
Children, with their tendency toward supple joints, generally tolerate well immobilization of the knee in full
flexion for a period of 2 to 3 weeks, with rapid return of full motion. Therefore, this flap should be limited to
use in children.
FLAP DESIGN AND DIMENSIONS
The buttock flap is a random-pattern flap that may be based either medially or laterally, depending on the
location of the defect to be resurfaced (Fig. 566.1). Flap length is generally 25 cm and width is 20 cm, although
the dimensions vary according to the sizes of the defect and the child. The inferior limits of the flap are kept 3
and 4 cm above the gluteal fold.
OPERATIVE TECHNIQUE
The flap is delayed by making the upper and lower transverse incisions and undermining the flap between them
above the gluteal fascia. The flap then is completely elevated 2 to 3 weeks later (following debridement of the
defect), the knee is flexed, and the flap is contoured and applied to the defect (Figs. 566.2 and 566.3). The
donor site is covered with a split-thickness skin graft.
Immobilization may be accomplished in a variety of ways, but it should maintain rather rigid fixation of knee
flexion. In the past, an Orthoplast splint was designed preoperatively and custom fit with padding. More recently,
Hoffmann external fixation (with pins in the femur and tibia) has been used and seems to offer several
advantages.
FIGURE 566.1 Flap design.
FIGURE 566.2 Contoured flap applied to defect.
FIGURE 566.3 Posttraumatic defect in a 6-year-old child. A: Open wound of foot and ankle. B: Buttock flap
applied to wound. C: Flap 6 weeks postoperatively.
The flap is divided (in one or more stages) and inset in 2 to 3 weeks. The patient then begins vigorous range-of-
motion exercises with the knee.
CLINICAL RESULTS
The major disadvantage of this flap is the need for immobilization of the knee in full flexion for a 2 to 3
weeks. Another major disadvantage is the random pattern of this flap, which necessitates delay. Although
complications are infrequent, one should consider flap separation due to inadequate immobilization, flap
necrosis due to inadequate delay or pedicle torsion, and loss of full range of motion of the knee.
SUMMARY
The ipsilateral buttock flap can be effectively used to cover defects of the ankle and foot in children.
References
1. Bennett JE, Kahn RA. Surgical management of soft-tissue defects of the ankle-heel region. J Trauma
1972;12:696.
2. Dalton RLG. Complications of the cross-leg flap operation. Proc R Soc Med 1972;65:626.